=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659082121
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ACCELERATED WELLNESS & AESTHETICS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/06/2022
-----------------------------------------------------
Last Update Date | 05/09/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3901 GEORGIA ST NE
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87110-1359
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-537-0052
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3901 GEORGIA ST NE STE E4
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87110-1388
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-916-5128
-----------------------------------------------------
Fax | 505-560-7399
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JOSEPH GILL
-----------------------------------------------------
Credential | NP
-----------------------------------------------------
Telephone | 505-916-5128
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------